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<head>
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<body bgcolor="{$STYLE.BGCOLOR2}">

<p><span class="title">Review Of Systems</span></p>

<form name="review_of_systems" method="post" action="{$FORM_ACTION}/interface/forms/review_of_systems/save.php"

 onsubmit="return top.restoreSession()">

<table>

<tr>

	<td colspan="6">

		<h3>Review of Systems</h3>

		<p> Enter only positive symptoms patient has had in last 2 weeks.</p>

	</td>

</tr>

<tr>

	<td class="title">Health</td>

</tr>

<tr>

	<td></td>

    <td colspan="3">When was your last tetnus shot?: <input type=text name="date_tetnus_shot" value="{$review_of_systems->get_date_tetnus_shot()}" ></td>

</tr>

<tr>

	<td></td>

    <td colspan="3">When was your last Pneumonia shot?:<input type=text name="date_pneumonia_shot" value="{$review_of_systems->get_date_pneumonia_shot()}" ></td> 

</tr>

	<td></td>

    <td colspan="3">When was your last Flu shot?:<input type=text name="date_flu_shot" value="{$review_of_systems->get_date_flu_shot()}" ></td> 

</tr>

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			<tr>

				{if !is_numeric($row_title)}

					<td>{$row_title}</td>

					<td class="form_text">{html_checkboxes name="checks" options=$row selected=$review_of_systems->checks separator="&nbsp;</td><td class=\"form_text\">"}</td>

					{if $row_title eq "Women"}

						</tr>

						<tr>

    						<td></td>

    						<td colspan="4" class="form_text">Date of last Pap Smear:  <input type=text name="date_pap_smear" value="{$review_of_systems->get_date_pap_smear()}" ></td>

						</tr>

						<tr>

							<td></td>

						    <td colspan="4" class="form_text">Date of last Mammogram:  <input type=text name="date_mammogram" value="{$review_of_systems->get_date_mammogram()}" ></td>

						</tr>			

						<tr>

							<td></td>

						    <td colspan="4" class="form_text">Date of last Bone Density Scan:  <input type=text name="date_bone_density_scan" value="{$review_of_systems->get_date_bone_density_scan()}" ></td>

						</tr>

						<tr>

							<td></td>

						    <td colspan="4" class="form_text">Have you ever had an abnormal Pap Smear:  <input type=text name="abnormal_pap_smear" value="{$review_of_systems->get_abnormal_pap_smear()}" ></td>

						</tr>

						<tr>

							<td></td>

						    <td colspan="4" class="form_text">Have you ever had an abnormal Mammogram:  <input type=text name="abnormal_mammogram" value="{$review_of_systems->get_abnormal_mammogram()}" ></td>

						</tr>

					{elseif $row_title eq "Men"}

						</tr>

						<tr>

    						<td></td>

    						<td colspan="4" class="form_text">Date of Last PSA: <input type=text name="date_last_psa" value="{$review_of_systems->get_date_last_psa()}" ></td>

					{elseif $row_title eq "When sexually active,<br> are you active with:"}

						<tr>

							<td></td>     

    						<td colspan="4" class="form_text">How many packs of cigarettes do you smoke per day:  <input type=text name="packs_per_day" value="{$review_of_systems->get_packs_per_day()}" ></td>

						</tr>

						<tr>     

							<td></td>

						    <td colspan="4" class="form_text">How many years have you smoked:  <input type=text name="years_smoked" value="{$review_of_systems->get_years_smoked()}" ></td>

						</tr>

						<tr>     

							<td></td>

						    <td colspan="4" class="form_text">How much alcohol do you drink a week:  <input type=text name="alcohol_per_week" value="{$review_of_systems->get_alcohol_per_week()}" ></td> 

						</tr>

						<tr>  

							<td></td>

						    <td colspan="4" class="form_text">If you use recreational drugs, please give us a list:  <input type=text name="recreational_drugs" value="{$review_of_systems->get_recreational_drugs()}" ></td>

					{/if}

				{else}

					<td width="20"></td>

					<td colspan="6"><table><tr><td class="form_text">

					{html_checkboxes name="checks" options=$row selected=$review_of_systems->checks separator="&nbsp;&nbsp;&nbsp;</td><td class=\"form_text\">"}

					{if $title eq "Precipitating Factors" and $row_title eq 2}

						&nbsp;<input type="text" name="precipitating_factors_other_text" size="15" value="{$review_of_systems->get_precipitating_factors_other_text()}">

					{/if}

					</td></tr></table></td>

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</tr>

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<tr>

	<td colspan="3"><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

<a href="{$DONT_SAVE_LINK}" class="link" onclick="top.restoreSession()">[Don't Save]</a></td>

</tr>

{/if}

</table>

<input type="hidden" name="id" value="{$review_of_systems->get_id()}" />

<input type="hidden" name="activity" value="{$review_of_systems->get_activity()}">

<input type="hidden" name="pid" value="{$review_of_systems->get_pid()}">

<input type="hidden" name="process" value="true">

</form>

</body>

</html>